The term leiomyoma defines a benign tumour composing mainly of uterine smooth muscle cells with varying amount of fibrous connective tissue. They are the most common tumours of uterus and female pelvis. There are mainly of 3 types: intramural (arising in the myometrium), submucosal or subserosal. Here we present an innovative method of myomectomy of a large symptomatic subserosal leiomyoma in an unmarried woman by a minilaparotomy incision and morcellation.
All leiomyomas arise from the myometrium to begin with i.e. they are intramural/interstitial. As they grow, they could extend inwards towards the endometrial cavity or outwards towards the peritoneal cavity and give rise to submucosal or subserosal leiomyomas respectively. (1) Large symptomatic leiomyomas warrant surgical excision.
A 35 years old, unmarried nulligravida, presented to the outpatient clinic with complaints of persistent dull aching lower abdominal pain for 2 years and a palpable mass per abdomen for 1 year. The pain was progressively increasing in intensity. There were no aggravating or relieving factors for the pain. There was no history of menstrual abnormalities. The patient had visited a private hospital 1 year back and a transabdominal ultrasonography (USG) was done, which showed a 7x 8 cm sized subserosal leiomyoma located at the fundus. She was advised conservative management with non steroidal antiinflammatory agents for pain relief and serial USG for follow-up. However, her symptoms continued to worsen. Hence she was referred to us. On examination, her general and systemic examination showed no abnormality. Abdominal examination showed a 24 weeks' size mobile, nontender mass. There was no tenderness, guarding or rigidity. Per speculum and per vaginal examinations were not done considering her unmarried status. A rectal examination showed the cervix was in continuity with the mass. USG was done which showed a 12 x 13 x 11 cm sized pedunculated subserosal fundal leiomyoma. Bilateral adnexal structures were normal. There was no evidence of hydroureter or hydronephrosis formation. Investigations for fitness for anesthesia showed normal results. Myomectomy was planned through a mini laparotomy incision. A minilaparotomy was done through a 5 cm long infra-umbilical midline vertical incision. Intraoperative findings showed a 15 x 12 cm large pedunculated subserosal leiomyoma, connected to the uterine fundus by a broad pedicle with leash of vessels within it. Bilateral fallopian tubes and ovaries were normal. There were no adhesions between the leiomyoma and the omentum or bowel, and no torsion of the pedicle. A rolled up gauze mop was passed around the pedicle and traction was made on the two ends of the mop, so that the pedicle was drawn forwards and fixed. The leiomyoma was grasped with a tenaculum near the pedicle. The pedicle was held with three Allis' forceps applied close to the uterine serosa, and divided above the grips of the forceps. The Allis' forceps were replaced by sutures of No. 1-0 polyglactin in two layers. Hemostasis achieved. Thus the leiomyoma was separated from the uterus and its blood supply was cut off, so that there would not be any blood loss during morcellation of the leiomyoma. Morcellation procedure was performed with a scalpel using wedge resection technique to reduce the size of the leiomyoma so that it could fit through the smaller incision. Fifteen wedges of different sizes were resected to facilitate the delivery of the leiomyoma through the small abdominal incision. During each wedge resection, the leiomyoma was pulled closer to the skin with the help of a tenaculum and long Allis’ forceps, so that a wedge could be cut out only from the surface which was visible through the incision and no tissue inadvertently spilled into the peritoneal cavity. This also made the use of any containment retrieval bag for the specimen unnecessary. The patient made an uneventful recovery. The leiomyoma weighed 625 g. Its histopathological confirmed the diagnosis of a leiomyoma.
Leiomyomas are smooth muscle tumors – commonest tumors of uterus. Most of them are small and asymptomatic, they just need observation by frequent pelvic examinations and ultrasonography to look for any rapid enlargement in size. Few may produce symptoms like abdominal pain – because of red degeneration, ulceration and infection or torsion of a large subserosal leiomyoma, dyspareunia, dysmenorrhea, menstrual irregularities – menorrhagia/menometrorrhagia which is more common with submucosal variety, postmenopausal bleeding, pressure symptoms leading to urinary retention/increased urinary frequency, infertility, spontaneous abortions and very rare complications like intravenous leiomyomatosis and sarcomatous change. Sarcomatous change is less common in subserosal variety as it contains more fibrous tissue. According to US FDA, chances of leiomyosarcoma are 1:458 grossly in uterine leiomyomas.
Expectant management can be done in asymptomatic leiomyomas and leiomyomas without any complications, where one is certain of its origin and benign nature of the mass. Symptomatic leiomyomas need surgical excision. Hysterectomy or myomectomy can be done after weighing the risks and benefits of each option. Myomectomy can be done especially when the patient desires her reproductive function. Myomectomy for subserosal leiomyomas can be done by an abdominal route (exploratory laparotomy/laparoscopically or robotic assisted). Laparoscopic or mini laparotomy routes have lot of advantages over an exploratory laparotomy because of which these approaches are preferred by most patients and surgeons - minimal postoperative discomfort, lesser chances of adhesions, hernia, less hospital stay, faster healing, better cosmesis.[3 to 6] But the complications associated with morcellation techniques also have to be considered - uterine perforation, bowel injury and direct trauma to other surrounding organs, dissemination of benign leiomyoma tissue leading to recurrence of ectopic or parasitic leiomyomas causing ‘Leiomyomatosis peritonealis disseminata’ or dissemination of an occult sarcoma. The most serious complication of abdominal intraperitoneal morcellation is the dissemination of an occult leiomyosarcoma, which will increase the stage of cancer and worsen its prognosis and patient 5 year survival rate, maximally seen with laparoscopic power morcellator.[9,10] The FDA has reported 1:350 chance of uterine sarcoma in patients undergoing hysterectomy or myomectomy for leiomyomas, but this is based only on a review of 9 retrospective single institution studies; rest of the studies show a much lower risk. FDA has issued warnings on the patient selection while considering morcellation to increase patient safety :
A) Laparoscopic power morcellators are contraindicated for removal of uterine tissue containing suspected leiomyomas in patients who are peri- or post-menopausal, or are candidates for en bloc tissue removal, for example through the vagina or mini-laparotomy incision. (Note: These groups of women represent the majority of women with leiomyomas who undergo hysterectomy.
B) Laparoscopic power morcellators are contraindicated in gynecologic surgery in which the tissue to be morcellated is known or suspected to contain malignancy.
Containment techniques are advised where different retrieval bags can be used to retrieve the sample and minimize dissemination of tissue and related complications.[11,12]
In our case, a small incision was used, the total length of which was equal to the cumulative lengths of the four abdominal incisions that would be required for laparoscopic myomectomy. Use of conventional technique reduced the cost tremendously as compared to laparoscopic surgery. Use of a rolled up gauze mop to make traction on the pedicle and trap it just below the abdominal wall incision was an innovative idea. It kept the pedicle trapped until it could be held with Allis’ forceps and cut. It also fixed the leiomyoma in position under the anterior abdominal wall until the pedicle was divided. Removing wedges of leiomyoma only from the part projecting out of the abdominal incision was another innovative idea. It prevented any unintentional, unanticipated spill of parts of the leiomyoma into the peritoneal cavity and resultant dissemination of occult malignancy (leiomyosarcoma) which is the greatest fear during any morcellation technique. The patient had a shorter hospital stay, cosmetically better scar, less postoperative pain as compared to a laparotomy.
- Buttram VC, Reiter RC. Uterine leiomyomata : etiology, symptomatology, and management. Fertil Steril 1981;36:433.
- US Food and Drug Administration. UPDATED Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication.http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm424443.htm.
- Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009;(3): CD003677.
- ACOG Committee Opinion No. 444: choosing the route of hysterectomy for benign disease. Am Cong Obst Gynecol 2009;114(5):1156–8.
- Worldwide AAMIG. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol 2011;18(1):1–3.
- Wiser A, Holcroft C, Tulandi T, Abenhaim H. Abdominal versus laparoscopic hysterectomies for benign disease: evaluation of morbidity and mortality among 465,798 cases. Gynecol Surg 2013;10:117–22.
- Naumann RW, Brown J. Complications of electromechanical morcellation reported in the manufacturer and user facility device experience (MAUDE) database. J Minim Invasive Gynecol 2015;22(6):1018e21.
- Administration FaD. UPDATED Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm424443.htm2014 [updated November 24, 2014; cited 2015 February 18].
- Leren V, Langebrekke A, Qvigstad E. Parasitic leiomyomas after laparoscopic surgerywith morcellation. Acta Obstet Gynecol Scand 2012;91:1233-6.
- Seidman MA, Oduyebo T, Muto MG, Crum CP, Nucci MR, Quade BJ. Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS One2012;7:50058.
- Solima E, Scagnelli G, Austoni V, Natale A, Bertulessi C, Busacca M, et al. Vaginal uterine morcellation within a specimen containment system: a study of bag integrity. J Minim Invasive Gynecol 2015; 22:1244–1246.
- Winner B, Porter A, Velloze S, Biest S. Uncontained compared with contained power morcellation in total laparoscopic hysterectomy. Obstet Gynecol 2015; 126:834–838.
- George S, Barysauskas C, Serrano C, Oduyebo T, Rauh-Hain JA, Del Carmen MG, et al. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma. Cancer 2014.
Parulekar M, Parulekar SV. Resection Of A Large Subserosal Leiomyoma By Minilaparotomy. JPGO. 2018 Vol 5 No. 10. Available from: http://www.jpgo.org/2018/10/resection-of-large-subserosal-leiomyoma.html